Healthcare Provider Details

I. General information

NPI: 1952192015
Provider Name (Legal Business Name): DENTAL IMPLANT SPECIALISTS OF NEVADA - WILLARDSEN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9061 W POST RD
LAS VEGAS NV
89148-2411
US

IV. Provider business mailing address

3500 MAPLE AVE STE 1150
DALLAS TX
75219-3949
US

V. Phone/Fax

Practice location:
  • Phone: 702-434-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JAMES WILLARDSEN
Title or Position: PROVIDER PARTNER
Credential:
Phone: 702-481-0089